Readmissions: OTs Role in Care

Frequent hospital readmissions have been a long standing problem, but with the 2010 health care reform law the consequences are becoming even steeper as fines will be imposed on hospitals with particularly high rates of Medicare frequent fliers.

The Jan 23rd issue of the Journal of the American Medical Association (JAMA) featured multiple articles on hospital readmissions, and would be a great resource for anyone interested in this topic. It features some initial studies and pilot programs for reducing readmissions that hospital OTs should be appraised of. Even if you just read the first page of Recasting Hospitals Role in a Community Context, it might spur some ideas. For example, the article talks about about a discharge protocol through which a collaborative cross-continuum team uses a 4-point model to reduce readmissions.  The 4 points are as follows: 

  1. Enhanced assessment of post-hospital needs
  2. Effective teaching to facilitate learning by patients and caregivers
  3. Post-hospital care follow up, including both medical and social services
  4. Communication of critical information as the patient transitions to the next clinician or health organization

These four points just shout OT. Working under this model might be a simple as purchasing the KELS to help with #1 or collaboratively filling out this discharge planning checklist with nursing and social services to address #2. 

We have always known good assessment of function, good teaching and good follow-up to be in our patients' best interest, but with fines looming your ideas for enacting these might capture your hospital's interest like never before.  

Could you use this evidence to make the discharge process better for some of your patients?

Are you underestimating your patients?

What's the story?

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